Provider Demographics
NPI:1053139147
Name:SCOTT, SHALISA DONNAY
Entity type:Individual
Prefix:
First Name:SHALISA
Middle Name:DONNAY
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6109 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7713
Mailing Address - Country:US
Mailing Address - Phone:479-407-9101
Mailing Address - Fax:
Practice Address - Street 1:3021 S FIR ST APT 4
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5665
Practice Address - Country:US
Practice Address - Phone:479-407-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR014071701382376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide